Valor prognóstico da função endotelial em portadores de aterosclerose: revisão sistemática / Prognostic value of endothelial function in patients with atherosclerosis: systematic review

A Vasodilatação Mediada por Fluxo (VMF) da artéria braquial, por meio da ultrassonografia, é um método de avaliação da função endotelial que pode oferecer informações fisiopatológicas, diagnósticas e prognósticas. A realização dessa revisão sistemática objetivou avaliar o nível de evidência na literatura a respeito da capacidade preditora da função endotelial, medida pela VMF da artéria braquial, por meio da ultrassonografia, quanto a eventos cardiovasculares, em indivíduos portadores de aterosclerose. Foram realizadas buscas nas bases de dados MEDLINE, SCIELO e LILACS e selecionados estudos de coorte prospectivos, em seres humanos, que analisaram o valor prognóstico da função endotelial medida pela VMF da artéria braquial, em populações portadoras de doença aterosclerótica, periférica ou coronariana. Trabalhos com evidentes vieses metodológicos foram excluídos. A seleção final constituiu-se de 15 estudos. Dos 13 estudos que, na análise univariada, mostraram significância estatística do método da VMF na predição de eventos cardiovasculares, 12 deles demonstraram sua capacidade preditora independente, em análise multivariada. Em nenhum dos trabalhos foi descrito valor prognóstico incremental em relação a modelos preditores tradicionais, como escore de Framingham. Resultados de três trabalhos sugerem que o método agrega valor prognóstico a marcadores isolados como: Índice Tornozelo-Braquial (ITB), diabetes e Proteína C Reativa (PCR) de alta sensibilidade. Em conclusão, a VMF da artéria braquial prediz risco cardiovascular, porém não é estabelecido seu valor preditor incremental a modelos prognósticos clínicos, não havendo, até o momento, evidências sólidas que amparem seu uso na rotina clínica para predição de risco cardiovascular.

Analysis of flow-mediated vasodilation (FMV) of the brachial artery by use of ultrasound allows assessing endothelial function, and provides pathophysiological, diagnostic and prognostic information. This systematic review was aimed at assessing the literature level of evidence of the predictive capacity of endothelial function, measured through brachial artery FMV by use of ultrasound, regarding cardiovascular events in individuals with atherosclerosis. The MEDLINE, SCIELO and LILACS databases were searched, and prospective cohort studies on human beings about the prognostic value of endothelial function, measured by use of brachial artery FMV in individuals with peripheral or coronary atherosclerosis, were selected. Studies with clear methodological biases were excluded. The final selection consisted of 15 studies. Of the 13 studies that on univariate analysis showed statistical significance of the FMV method to predict cardiovascular events, 12 showed independent predictive capacity on multivariate analysis. None of the studies reviewed described the incremental predictive value of FMV to the traditional predictive models, such as the Framingham score. Results of three studies have suggested that the method adds prognostic value to isolated markers such as ankle-brachial index (ABI), diabetes, and high-sensitivity C-reactive protein (hsCRP). In conclusion, brachial artery FMV predicts cardiovascular risk, but its incremental predictive value to clinical prognostic models has not been established. In addition, solid evidence supporting its use in routine clinical practice to predict cardiovascular risk still lacks.

Limitação funcional e claudicação intermitente: impacto das medidas de pressão arterial / Functional limitation and intermittent claudication: impact of blood pressure measurements

FUNDAMENTO: A hipertensão arterial é importante fator de risco para Doença Arterial Obstrutiva Periférica dos Membros Inferiores (DAOMI). Entretanto, a correlação entre pressão arterial e Pressão de Pulso (PP) com a gravidade da DAOMI e o prejuízo funcional decorrente dessa doença ainda não está bem estabelecida na população brasileira. OBJETIVO: Verificar se há correlação entre pressão arterial, PP, gravidade da DAOMI e capacidade funcional de pacientes com DAOMI sintomática. MÉTODOS: FORAM avaliados 65 pacientes (62,2 ± 8,1 anos; 56,9 por cento do sexo masculino), divididos em dois grupos: pressão arterial normal (A) e elevada (B). A gravidade da DAOMI foi avaliada por meio do Índice Tornozelo-Braquial (ITB) e a capacidade funcional, pelas distâncias total e livre de dor percorridas em teste de marcha. RESULTADOS: O grupo A foi constituído por 17 (26,1 por cento) pacientes. A Pressão Arterial Sistólica (PAS), diastólica e a PP foram, respectivamente, 125,4 ± 11,7; 74,5 ± 9,1 e 50,9 ±10,0 mmHg, para o grupo A, e 160,7 ± 19,6; 90,0 ± 12,2 e 70,7 ± 20,2 mmHg, para o grupo B. O ITB foi significativamente menor no grupo B (0,66 ± 0,12 vs 0,57 ± 0,13, p < 0,05). PAS e PP correlacionaram-se com a gravidade da DAOMI e com as distâncias percorridas em teste de marcha. Pacientes com PP > 40 mmHg percorreram menores distâncias. CONCLUSÃO: A PAS e a PP correlacionaram-se de forma significativa com as distâncias percorridas em teste de marcha, sugerindo que sejam marcardores clínicos da limitação da capacidade funcional em pacientes com DAOMI sintomática.

BACKGROUND: Arterial hypertension is an important risk factor for Lower-Limb Occlusive Arterial Disease (LLOAD). However, the correlation between blood pressure and pulse pressure (PP) with LLOAD severity and functional impairment resulting from this disease is not well established in the Brazilian population. OBJECTIVE: To verify whether there is a correlation between blood pressure, PP, LLOAD severity and functional capacity in patients with symptomatic LLOAD. METHODS: A total of 65 patients (62.2 + 8.1 years, 56.9 percent males) were evaluated. They were divided into two groups: normal (A) and high (B) blood pressure. LLOAD severity was assessed using the ankle-brachial index (ABI) and functional capacity by the total and pain-free walking distance at the 6-minute walking test (6MWT). RESULTS: Group A consisted of 17 (26.1 percent) patients. The systolic (SBP), diastolic blood pressure (DBP), and PP were, respectively, 125.4 ±11.7, 74.5 ± 9.1 and 50.9 ± 10.0 mmHg in group A and 160.7 ± 19.6, 90.0 ± 12.2 and 70.7 ± 20.2 mmHg in group B. The ABI was significantly lower in group B (0.66 ± 0.12 vs. 0.57 ± 0.13, p <0.05). SBP and PP correlated with LLOAD severity and the distances walked at the 6MWT. Patients with PP > 40 mmHg walked shorter distances. CONCLUSION: SBP and PP significantly correlated with the distances walked in the 6MWT, suggesting they are clinical markers of functional capacity impairment in patients with symptomatic LLOAD.

Oxidized low-density lipoprotein and ankle-brachial pressure index in patients with clinically evident peripheral arterial disease

OBJECTIVES: To investigate whether oxidized low-density lipoprotein is a suitable predictor of peripheral arterial disease severity. The role of oxidized low-density lipoprotein in the pathogenesis of atherosclerosis has already been investigated. Its relevance as a predictor of the appearance and worsening of coronary arterial disease is also well known. However, the same is not true regarding peripheral arterial disease. METHOD: Eighty-five consecutive patients with an ankle-brachial pressure index (ABPI) < 0.9 and the presence of either intermittent claudication or critical lower leg ischemia were included. The plasma level of IgG autoantibodies against oxidized low-density lipoprotein was evaluated through an enzyme-linked immunosorbent assay. The results were categorized into quartiles according to the ankle-brachial pressure index (a marker of peripheral arterial disease severity), and significant differences were investigated with the Kruskal-Wallis test. RESULTS: There was no significant difference between the quartiles for this population (p = 0.33). No correlation was found between the ankle-brachial pressure index and oxidized low-density lipoprotein levels in subjects with clinically evident peripheral arterial disease with a wide range of clinical manifestations. CONCLUSIONS: Oxidized low-density lipoprotein is not a good predictor of peripheral arterial disease severity.

Alteração do arco longitudinal medial na neuropatia periférica diabética / Medial longitudinal arch change in diabetic peripheral neuropathy

OBJETIVO: Descrever e comparar as características antropométricas dos pés de sujeitos saudáveis e diabéticos neuropatas por meio de índices classificatórios do Arco Longitudinal Medial (ALM): Índice do Arco (IA), Índice de Chippaux-Cmirak (CSI) e Ângulo  (Â) e comparar a classificação destes métodos nestes grupos. MATERIAIS E MÉTODO: Grupo controle (GC) composto por 21 sujeitos saudáveis, e grupo diabético (GD), formado por 46 diabéticos portadores de neuropatia diabética. Pela impressão plantar foram calculados os índices. RESULTADOS: Houve maior proporção de pés planos no GD para os três índices (IA: 32,2 por cento, CSI: 59,7 por cento, A: 17,5 por cento), enquanto os pés cavos comportaram-se de forma contrária. Os grupos foram estatisticamente diferentes em relação à proporção de pés planos no IA (p=0,0080) e no CSI (p=0,0000) e de pés cavos no  (p=0,0036). Houve diferença significativa quando comparados GC e GD para os três índices: IA (p=0,0027), CSI (p=0,0064),  (p=0,0296). CONCLUSÃO: Os dados demonstram alterações motoras e ortopédicas decorrentes da neuropatia periférica, responsável pela desestruturação do pé, levando ao desabamento do ALM. Observou-se que o ângulo A destoou fortemente da classificação do arco feita pelos outros dois índices, e com isso destacamos que sua utilização merece cuidado.

OBJECTIVE: To describe and compare foot anthropometry in healthy and diabetic subjects using Medial Longitudinal Arch (MLA) classificatory indexes: Arch Index (AI), Chippaux-Smirak Index (CSI) and  Angle (Â), as well as to compare the classification of these methods in each group. MATERIALS AND METHODS: Control Group (CG) composed by 21 healthy subjects and Diabetic Group (DG), with 46 diabetic neuropathy subjects. The indexes were calculated from footprints. RESULTS: A larger proportion of flat feet was seen in DG for the three indexes (AI: 32,2 percent, CSI: 59,7 percent, A: 17,5 percent), while highly arched feet acted oppositely. The groups were statistically different for the proportion of flat feet in AI (p=0,0080) and CSI (p=0,0000) and high feet in  (p=0,0036). There were significant differences when compared GC and GD in the three indexes: IA (p=0,0027), CSI (p=0,0064),  (p=0,0296). CONCLUSION: Data showed motor and orthopedic changes originated by peripheral neuropathy, which is responsible for foot changes, causing longitudinal arch crumbling. It was seen that A Angle strongly disagreed when compared with the arch classification made by the other two indexes and therefore, its application needs care.

Comparison of removable rigid dressing and elastic bandage in reducing the residual limb volume of below knee amputees.

OBJECTIVE: Compare the reducing volumes of the residual limbs between the removable rigid dressing method and the elastic bandaging technique. STUDY DESIGN: Randomized controlled trial. Setting: Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital. MATERIAL AND METHOD: Twenty-six below-the-knee amputees (11 men (42.3%) and 15 women (57.69%)) who were informed and gave written consents were included in this study. The mean age was 68.19 +/- 10.83 years. The patients who met the eligible criteria were randomized into two groups. Fourteen subjects (53.8%) were in the EB group and 12 (46.2%) in the RRD group. The first group was taught to use a removable rigid dressing (RRD) while the second group was taught to use an elastic bandage (EB) for stump shaping and volume reduction. Both groups were trained with the same pre-prosthetic program. The circumference of the stump was measured and calculated for volume at the beginning, 2 weeks, and 4 weeks. The volume reduction was compared between the two groups. RESULTS: Twenty subjects were amputated on the right side (76.92%). The majority underlying was diabetes mellitus (80.77%). Fifteen cases of amputation were peripheral vascular disease (57.69%). The stump volume reduction of the RRD group at 2 and 4 weeks were 42.73 +/- 62.70 and 79.9 +/- 103.33 cm3, respectively. The stump volume reduction of the EB group were 21.89 +/- 118.49 and 83.03 +/- 113.05 cm3, respectively. There were no statistically significant differences of volume reduction between the two groups at 4 weeks. CONCLUSION: Removable rigid dressing had a tendency to reduce residual limb volume of below knee amputees faster than elastic bandage at 2 weeks but the decreasing volumes were not different at 4 weeks.

Índice Tornozelo-Braquial (ITB) determinado por esfigmomanômetros oscilométricos automáticos / Assessing Ankle-Brachial Index (ABI) by using automated oscillometric devices

FUNDAMENTO: Índice Tornozelo-Braquial (ITB) é essencial na prática clínica, mas dificuldades técnicas na sua execução pelo padrão de referência Doppler vascular (DV) tornam-no ainda pouco utilizado. OBJETIVO: Avaliar aplicabilidade da determinação do ITB com uso de esfigmomanômetros oscilométricos automáticos (EOA) e sugerir a utilização dos índices delta-Bráquio-Braquial (delta-BB) e delta-ITB como marcadores de risco cardiovascular. MÉTODOS: Estudo descritivo e observacional de 247 pacientes ambulatoriais (56,2 por cento feminino, média 62,0 anos) submetidos à determinação do ITB com aferição simultânea da pressão arterial (PA) em membros superiores (MMSS) e inferiores (MMII) utilizando-se dois EOA (OMRON-HEM705CP). Nos casos em que não foi possível aferir PA em pelo menos um dos MMII utilizou-se DV. Os pacientes divididos em Grupo N (ITB normal: 0,91 a 1,30) e Grupo A (ITB alterado: <0,90 ou >1,30) tiveram comparados entre si os valores de delta-ITB (diferença absoluta ITB/MMII) e delta-BB (diferença absoluta PAS/MMSS). RESULTADOS: Utilizando-se EOA foi possível determinar ITB em 90,7 por cento. Com dados do Grupo N determinaram-se valores de referência (VR) no percentil 95 de delta-ITB (0-0,13) e delta-BB (0-8 mmHg). Quando comparado com o Grupo N, o Grupo A apresentou prevalência mais elevada tanto de delta-ITB (30/52 contra 10/195; Razão de Chances: 25,23; p<0,0001) como de delta-BB (13/52 contra 7/195; Razão de Chances: 8,95; p<0,0001) acima dos VR. CONCLUSÃO: O ITB pode ser determinado na maioria das vezes com EOA. Delta-ITB e delta-BB acima dos VR estiveram significativamente mais prevalentes nos portadores de ITB alterado e podem ser sugeridos como marcadores de risco cardiovascular em futuros estudos epidemiológicos.

BACKGROUND: Assessing Ankle-Brachial Index is an essential procedure in clinical settings, but since its measurement by the gold standard Doppler Ultrasonic (DU) technique is impaired by technical difficulties, it is underperformed. OBJECTIVE: The aim of this study was to assess the efficacy of an automated oscillometric device (AOD) by performing Ankle-Brachial Index (ABI) assessments and to suggest delta brachial-brachial (delta-BB) and delta-ABI as markers of cardiovascular risk. METHODS: In this observational and descriptive study, 247 patients (56.2 percent females, mean age 62.0 years) had their arterial blood pressure (ABP) measured for ABI calculation. Two AOD (OMRON-HEM705CP) devices were used for simultaneous measurements of the ABP, first of the two arms and then of the arm with higher systolic ABP and a leg, first the left and then the right one. When leg ABP measurements were not possible, ABI determination was performed by using the standard Doppler Ultrasonic (DU) technique. Patients were designated to Group N (normal ABI: 0.91 to 1.30) or Group A (abnormal ABI: <0.90 or >1.30). Other indexes were also calculated: delta-BB (absolute difference in mmHg of systolic ABP between arms) and delta-ABI (absolute difference of ABI between legs) and the results were compared. RESULTS: In most patients (90.7 percent), it was possible to determine the ABI. Group N data allowed calculation of the 95th percentile reference values (RV) of delta-BB (0 to 8 mmHg) and delta-ABI (0 to 0.13). When compared to Group N, Group A had a significantly higher prevalence of high values greater than the RVs of delta-ABI (30 of 52 and 10 of 195, respectively; Odds Ratio = 25.23; p<0.0001) and delta-BB (13 of 52 and 7 of 195, respectively; Odds Ratio = 8.95; p<0.0001). CONCLUSION: In most patients, the ABI could be measured by AOD. Both indexes, delta-BB and delta-ABI greater than the RVs, were significantly more prevalent in patients with abnormal ABI ...

Qualidade do sono em pacientes idosos com patologias vasculares periféricas / Sleep quality in aged patients with peripheral vascular diseases

Patologias vasculares periféricas freqüentemente acometem idosos e, sendo crônicas, interferem na qualidade de vida desses indivíduos, inclusive no sono. Portanto, este estudo objetivou avaliar a qualidade do sono de idosos com patologias vasculares periféricas em acompanhamento ambulatorial no Hospital das Clínicas da Universidade Estadual de Campinas. Os voluntários (n=50, idade média de 74 8 anos) responderam ao Índice de Qualidade de Sono de Pittsburgh (PSQI), forneceram dados sociodemográficos e sobre a vasculopatia (35 idosos apresentavam obstrução arterial em membros inferiores). Verificou-se que 34 idosos apresentavam sono de má qualidade. A duração do sono era de 5,8 ( 2,3) horas e, segundo 23 idosos, as dores perturbavam o sono noturno freqüentemente (três vezes na semana ou mais). Somente 18 idosos usavam analgésicos e quatro, medicamentos para dormir. Os achados podem subsidiar o enfermeiro na implementação de medidas para melhorar esse quadro e promover a qualidade de vida das pessoas acometidas.

Peripheral vascular diseases (PVD) are prevalent among the elderly, and, due to their chronic character, result in poor quality of life and poor sleep quality. This study aimed at evaluating sleep quality of elderly people diagnosed with PVD who undergo clinical ambulatory treatment in a university hospital in Campinas, in the State of São Paulo. Subjects (n=50, aged 74 8 years old) answered the Pittsburgh Sleep Quality Index (PSQI) and provided basic demographic data and PVD history (35 subjects had arterial blockage in lower limbs). Results showed that 34 subjects presented bad sleep quality; sleep length was 5.8 ( 2.3) hours, and, according to 23 subjects, night sleep was frequently disturbed by pain (thrice a week or more). Eighteen subjects took analgesics; four took sleep medicines. Findings may have important implications for nurses working with PVD patients, stressing the need to take into account consequences of PVD on sleep disturbances when planning their interventions.

Las patologías vasculares periféricas frecuentemente acometen a las personas de la tercera edad y, siendo crónicas, interfieren en la calidad de vida de esos individuos, inclusive en el sueño. Por tanto, en este estudio se tuvo por objetivo evaluar la calidad del sueño de personas de la tercera edad con patologías vasculares periféricas en tratamiento ambulatorio en el Hospital de las Clínicas de la Universidad Estatal de Campinas. Los voluntarios (n=50, edad media de 74 8 años) respondieron al Índice de Calidad de Sueño de Pittsburgh (PSQI), proporcionaron sus datos sociodemográficos y sobre la vasculopatía (35 personas de la tercera edad presentaban obstrucción arterial en miembros inferiores). Se verificó que 34 personas de la tercera edad presentaban sueño de mala calidad. La duración del sueño era de 5,8 ( 2,3) horas y, según 23 de los participantes, los dolores perturbaban su sueño nocturno frecuentemente (tres veces en la semana o más). Sólo 18 de ellos usaban analgésicos y cuatro, medicamentos para dormir. Los hallazgos pueden ayudar al enfermero en la implementación de medidas para mejorar ese cuadro y promover la calidad de vida de las personas acometidas.

Análise de fatores associados à ulceração de extremidades em indivíduos diabéticos com neuropatia periférica / Analysis of factors associated with extremity ulceration in diabetic subjects with peripheral neuropathy

A neuropatia periférica é o principal fator de risco para ulceração em pé de indivíduos diabéticos. Este estudo testou a associação de doença arterial periférica (DAP) à ulceração do pé em amostra de pacientes com neuropatia sensório-motora simétrica distal e se marcadores inflamatórios subclínicos também se associariam a esse evento. Foram avaliados 32 indivíduos diabéticos tipo 2 com exame do monofilamento de 10 g alterado, estratificados em 2 grupos segundo a história ou presença de úlcera nas extremidades inferiores. O grupo "com úlcera" (n = 18) incluiu aqueles que apresentavam úlcera ativa ou cicatrizada, ou que tiveram alguma amputação em membro inferior decorrente de complicações da úlcera. Além do exame neurológico e monofilamento, foram submetidos a bioestesiometria, avaliação vascular com Doppler e exames laboratoriais. Os grupos foram semelhantes quanto à distribuição dos sexos, média de idade e tempo de diabetes. O grupo com úlcera apresentou valores médios de altura (1,70 ± 0,06 vs. 1,63 ± 0,11 m; p = 0,044) e limiar de percepção vibratória no maléolo medial (40,9 ± 13,0 vs. 30,6 ± 12,3 V; p = 0,040) mais elevados que o sem a úlcera. Os grupos não diferiram entre si quanto à média dos marcadores inflamatórios. A resposta do reflexo patelar foi também pior no grupo com úlcera (p = 0,047), no qual se observou maior proporção de indivíduos com o índice hálux-braquial alterado (p = 0,030) quando comparado ao sem úlcera. Conclui-se que a DAP está associada à presença de úlcera (atual ou pregressa) em membros inferiores de indivíduos diabéticos neuropatas. A pesquisa de alteração de fluxo de artérias digitais de membro inferior (no hálux) contribuiu para detectar tal associação. Associação de neuropatia ulcerada a marcadores inflamatórios não foi observada, não sendo possível excluí-la devido às limitações do tamanho da amostra. Estudos prospectivos deverão examinar a sensibilidade do índice hálux-braquial...

Peripheral neuropathy is the main risk factor for foot ulceration in diabetic subjects. This study examined the association of peripheral arterial disease (PAD) with foot ulceration in a sample of diabetic subjects with peripheral neuropathy, and also if inflammatory markers would be associated with this event. We evaluated 32 type 2 diabetic individuals with abnormal 10-g monofilament exam, who were stratified in 2 groups according to history or presence of lower extremities ulcer. The group "with ulcer" (n = 18) included the ones that had active or cicatrized ulcer, or some lower-extremity amputation due to ulcer complications. In addition to the neurological examination and monofilament test, they were submitted to biothesiometry, lower extremity vascular assessment with Doppler, and laboratory determinations. No difference between the groups was found concerning sex distribution, mean age, and duration of diabetes diagnosis. The group with ulcer showed higher mean values of height (1.70 ± 0.06 vs. 1.63 ± 0.11 m, p = 0.044), vibration perception threshold measured in medial malleolli (40.9 ± 13.0 vs. 30.6 ± 12.3 V, p = 0.040) than the group without ulcer. The groups did not differ regarding the mean values of the inflammatory markers. Response to patellae reflex was worse in the group with ulcer (p = 0.047), in which a higher proportion of individuals with abnormal toe-brachial index (p = 0.030) was observed as compared to those without ulcer. We concluded that PAD is associated with the presence of ulcer in neuropathic subjects. The assessment of digital arteries flow in lower limbs (in great toe) contributed to detect such association. Association of diabetic foot ulcers and inflammatory markers was not observed, but cannot be excluded due to limitations of sample size. Prospective studies should examine the sensitivity of the toe-brachial index to identify PAD in diabetic individual at risk of ulceration.

Avaliação da função muscular em doença arterial obstrutiva periférica: a utilização da dinamometria isocinética / Assesment of muscular function on peripheral arterial obstructive disease: the use of isokinetic dynamometry

Indivíduos com doença arterial obstrutiva periférica apresentam perda funcional, principalmente em membros inferiores, gerando prejuízo da capacidade de caminhada. Os testes de caminhada são rotineiramente utilizados para avaliação e seguimento desses pacientes. Em pacientes idosos, com comorbidades e limitações associadas à claudicação intermitente, torna-se difícil a avaliação pela caminhada, principalmente nos casos de doença bilateral com acometimento desigual, onde o membro mais afetado limita a avaliação do menos afetado. A avaliação muscular isocinética é uma metodologia alternativa aos testes de caminhada para avaliar de forma individualizada as perdas funcionais geradas pela doença nos diferentes grupamentos musculares em territórios isquêmicos.

Individuals with peripheral arterial obstrutive disease presents functional losses, mainly in the lower limbs, generating an impaired walking capacity. Walking tests are routinely used for evaluation and follow up of these patients. In elder patients, with comorbities and limitations associated with intermittent claudication, the evaluation by walking tests becomes difficult, mainly in the cases of bilateral disease with different affection, where the less diseased limb limits the evaluation of the most diseased limb. The muscular isokinetic assessment is an alternative methodology of walking tests to individually evaluate the disease generated functional losses in the different muscular groupings in ischemic territories.

Correlação da dislipidemia nos pacientes com isquemia crítica do Hospital Barão de Lucena - Recife/PE / Correlation of dyslipidemia in patients with critical ischemia in Hospital Barão de Lucena - Recife/PE

PURPOSE: There are studies that confirm the association between dyslipidaemia and the genesis of atherosclerosis process in world literature. The goal of this study is to evaluate the incidence of the dyslipidaemia in patients with critical limb ischemia. METHODS: The analysis was made in fifty in-patients from Vascular Surgery Service from Barão de Lucena Hospital from September 2003 to August 2004. We analyzed the laboratorial tests and seen the frequency the lipids abnormalities in fifty patients. RESULTS: Among the patients evaluated 62.2% was women and 37.8% was men. The incidence of abnormalities in the lipids levels was 39.2% in women and 31.5% in the men. It was not possible to determinate the relationship between the lipids levels and the intensity of atherosclerotic lesions. CONCLUSIONS: There is a significant incidence of dyslipidaemia in the patients evaluated. All data are similar to the ones observed in the in the literature.

Enfermedad arterial periferica oclusiva / Peripheral arterial occlusive disease

La enfermedad arterial periférica oclusiva, causada principalmente por la aterosclerosis, tiene una elevada morbilidad, en especial en el anciano. Su manifestación clínica principal, en su etapa temprana, es la claudicación intermitente. En esta revisión se analizan los aspectos más importantes para el estudio y manejo de la claudicación intermitente, que incluye datos epidemiológicos, factores de riesgo (tabaquismo, hipertensión arterial, diabetes mellitus, hiperlipidemia, obesidad, sedentarismo, niveles elevados de fibrinógeno y de homocisteína), historia natural, cuadro clínico, métodos diagnósticos, diagnóstico diferencial, tratamientos dirigidos a modificar los factores de riesgo (programa de ejercicios y terapia farmacológica) y manejos quirúrgicos (endovascular o cirugía de revascularización) que mejoren la calidad de vida y conserven la integridad del miembro afectado.

Anatomía vascular patológica / Vascular pathologic anatomy

La enfermedad vascular periférica es una de las manifestaciones de la enfermedad generalizada denominada ateroesclerosis. Esta enfermedad es la principal causa de infarto cardiaco, evento cerebral y gangrena de las extremidades, y es la responsable de casi 50 por ciento de todas las muertes en el mundo occidental. Los primeros síntomas de la enfermedad arterial obstructiva se desarrollan generalmente cuando existe un estrechamiento del 50 por ciento de la luz vascular. Dos Santos estableció que la cirugía vascular reconstructiva "es la cirugía de ruinas", este concepto explica el éxito de la cirugía vascular en la enfermedad aterosclerosa del segmento femoropoplíteo y distal.

role of von-wellbrand's factor; fibronectin and lipid profile as risk factors for vascular damage in rheumatoid arthritis and systemic sclerosis

This study was designed to determine the roles of Von-Willbrand's factor, fibronectin and lipid profile as risk factors in etiopathogensis of vascular lesions in 20 rheumatoid disease patients [RD] diagnosed according to American Rheumatism Association Criteria and 20 Systemic Sclerosis patients [SSc] diagnosed according to the preliminary criteria for SSc. 20 healthy subjects of matched age and sex were included as control group. Variable degrees of vascular lesions were detected: Raynouds phenomenon [RD 30%, SSc 50%] cutaneous telangiectasia and digital ulcers [RD 5%, SSc 40%], peripheral vascular insufficiency via Doppler study [RD 5%, SSc 40%], clinically evident systemic hypertension [SSc 15%], pulmonary vascular disease via Echo-Doppler study [RD 5%, SSc 20%], Coronary heart disease via E.C.G and Echo-Doppler study [20% in RD, 15% in SSc] and clinically evident cerebrovascular strokes [RD 10% SSc 10%]. The mean plasma levels of Von-Willebrand's factor and fibronectin were significantly higher in RD and SSc patients than in controls and the highest levels were observed in patients with vascular manifestations particularly with SSc., suggesting the presence of endothelial dysfunction and were considered as non invasive markers of vascular damage which are more prominant in SSc than in RD. The total serum lipids, Triglycerides, cholesterol, LDL-cholesterol, free fatty acids and Apoprotein B-were, significantly increased while HDL-cholesterol and apoprotein A, were significantly decreased, suggesting the presence of atherogenic dyslipidemic pattern in the etiopathogenesis of vascular manifestations in RD and SSc. The higher levels which observed in RD patients with vascular manifestations are most probably due to patients inactivity resulting from articular lesions or due to steroid therapy induced dyslipedemia. Circulating levels of endothelial cell products such as VWF and fibronectin may reflect the role of the immune mechanism in the pathogenesis of RD and SSc vascular disease and assist the clinician in monitoring response to therapy. Furthermore, monitoring of VWF and fibronectin as parameters of endothelial cell injury may help to define the vascular disease in an early and more measuringful fashion

Dor nos membros inferiores / Pain in the lower limbs

Os autores revisam as principais causas de dor nos membros inferiores enfocando os aspectos clínicos que contribuem para o diagnóstico diferencial entre os quadros oriundos dos sistemas músculos-esquelético, nervoso e vascular.

Disminución de la capacidad física como un factor de riesgo / Disminution of the physical capacity as a risk factor

A cien trabajadores del Instituto Mexicano del Seguro Social se les determinó el consumo máximo de oxígeno, a través de una prueba indirecta de fácil aplicación y bajo costo, en un banco ergométrico, para conocer su capacidad física. De la población en estudio 50 por ciento presentó una capacidad física disminuida, como consecuencia principalmente del sedentarismo. Sólo 44 por ciento de la población se encontró en buen estado de salud, mientras que el resto, 56 por ciento, presentó algún problema médico, generalmente no incapacitante, entre los que destacaron el sobrepeso y la obesidad: en 47 por ciento hubo sobrepeso y en 7 por ciento obesidad. El consumo máximo de oxígeno disminuyó en forma discreta con el incremento de la edad y fue superior en el sexo masculino

Arteritis de Takayasu / Takayasu's arteritis

Revisamos los casos de Arteritis de Takayasu (AT) diagnosticados en el Hospital Cayetano Heredia entre 1970 y 1988. Reportamos 7 pacientes con diagnóstico angiógrafico de AT, todas mujeres, seis de raza mestiza y una blanca. El tiempo de enfermedad promedio al diagnóstico fue de 7 años (rango:4 meses a 15 años). Los pacientes tuvieron síntomas sistémicos (fiebre, artralgias, cefalea); síntomas y signos de estenosis vascular (claudicación, hipertensión), todos presentaron soplos vasculares y seis ausencias de pulsos. Se documentó por estudio angiográfico varias zonas de compromiso arterial con diferentes combinaciones de lesiones: irregularidad, estenosis y obstrucción del lumen. Con el uso de esteroides y citotóxicos se logró el control y una buena evolución. Una paciente requirió "bay pass" coronario y tuvo seguimiento satisfactorio por 5 años